Practice Management Alert

Going slow now could save your practice and your patients headaches tomorrow.

An ABN (Advance Beneficiary Notice) lays out exactly what product or service might not be covered, why it might not be covered, and what the patient might need to pay. So it’s vital that you take the time to walk the patient through all of the information they need or you could have significant problems with patient push-back.

“The ABN should not be filled out at the front desk, which is where it’s usually done,” says Tracy Holt, MHR, COPC, account manager for Eye Care Leaders. Instead, a knowledgeable staff member should come into the exam room to go over all the details.

Slow and steady is better than fast and faulty. This process takes time and patience. Efficiency is obviously a priority for all practices, but this should not be rushed. Answer all the patient’s questions, and give them time (as CMS says) “to consider the options and make an informed choice.” Give them plenty of notice, so they don’t feel pressured before they decide whether or not to pursue the procedure.

Guide Patients Through the Ins and Outs

The ABN seems like a simple one-page form, but it’s not as simple as it looks. Consider the following advice for each section when reviewing it with your patients:

Blanks A-C. CMS calls you the “notifier,” and you should include the name, address and contact information of your practice at the very top of the form (though that isn’t clear from the form). The “patient name” should be an exact match for what’s on their Medicare card. And the “identification number” doesn’t refer to the patient’s Medicare or Social Security number, but rather any internal number you use to keep track of records. This last number is entirely optional, by the way, but it makes it much easier to locate records later.

Blanks D-F. Column D covers the product or service in question. This should include both codes and descriptions, so that the patient fully understands what’s being discussed. In column E, you lay out, in what CMS calls “beneficiary-friendly language,” why these services might not be covered. Each item in Column D should have a corresponding explanation in column E. For column F, CMS only requires you to make a “good faith effort” at estimating the cost to the patient.

Section G. The “options” section is where the patient takes over and makes a decision about the information you’ve provided. CMS underlines that you can’t make this decision for them. The patient is supposed to fill this section out on their own (though often, Holt notes, the staff member will end up completing it). Either way, you must understand the three options so that you can fully educate the patient and remain compliant:

• Option 1: The beneficiary agrees to pay for the service if it isn’t covered. When you file a claim and Medicare doesn’t pay, the beneficiary can appeal. Best practice: Collect the payment that day, and only reimburse the patient if Medicare surprises you and pays for the service.
• Option 2: The beneficiary agrees to pay for the non-covered items up front out of pocket, but no Medicare claim is filed and they can’t appeal.
• Option 3: The beneficiary rejects the service and doesn’t bother appealing.

Blanks H-J. This is where you, the notifier, can add any additional information that might clarify matters for the patient - insurance information or the signature of another witness, for example. And while it seems obvious, the signature and date in blanks I and J are all-important; they indicate that the beneficiary received and understood the information in the ABN. They also make the form legally binding.

Collect then and there. In ABN cases, it just makes sense to collect payment the same day, both to protect your practice and the patient. “We would generally not fill any order without at least half down, whatever the patient responsibility was,” Holt offers.

But What If the Patient Pushes Back?

If the patient refuses to sign the ABN, you can still go on with the service and bill them. Just keep in mind that “you probably will never receive payment from them,” advises Rhonda Buckholtz, CPC, CPCI, CPMA, CDEO, CRC, CHPSE, COPC, CENTC, CPEDC, CGSC, vice president of strategic development for Eye Care Leaders. But “when the physician feels the service is needed and will provide the service anyway, due to the clinical condition of the patient,” it may make sense to go forward and take the financial hit.

Here’s what you do when:

• The patient accepts some services but not all. You can provide separate ABNs for each service. CMS says that “the notifier can furnish an additional ABN listing the items/services the beneficiary wishes to receive with the corresponding option.”
• The patient won’t choose an option in section G. You make a note on the form and file it. CMS says that “if the beneficiary cannot or will not make a choice, the notice should be annotated, ‘Beneficiary refused to choose an option.’”
• The patient won’t sign the form. See above. CMS says that “If a beneficiary refuses to sign a properly issued ABN, you should consider not furnishing the item or service unless the consequences (health and safety of the beneficiary or civil liability in case of harm) prevent this option,” CMS says. But if you’ve taken the time to properly educate the patient all along the way, chances are they’ll sign the ABN.

Keep a copy! CMS requires you to “retain a copy of the ABN delivered to the patient on file” for five full years, “even if the patient declined the care, refused to choose an option, or refused to sign the ABN.”

For more information and forms: Visit cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html